Cancer Support Group

Saturday, Jul 11th

Last update:06:42:40 AM GMT

Case Discussion

Case 4
  • Abnormal uterine bleeding develops in a 72-year old woman who is taking tamoxifen as adjuvant treatment for a stage II estrogen-receptor (ER)-positive breast cancer. On examination , an adenocarcinoma of the endometrium is found. Other than mild hypertension, the patient has no substantial co morbid medical conditions.
  • Which of the following is the most appropriate next step in the treatment of this patient
Objectives
  1. Aggressive surgery because the cancer is likely to be poorly differentiated and locally advanced.
  2. Standard surgery followed by six cycles of adjuvant chemotherapy with cisplatin and doxorubicin.
  3. Standard surgery as used to treat endometrial cancer not related to the prior use of tamoxifen.
  4. Oral progesterone therapy until disease progression.
  5. Discontinuation of treatment with tamoxifen and then observation.
Correct Answer
  1. Aggressive surgery because the cancer is likely to be poorly differentiated and locally advanced.
  2. Standard surgery followed by six cycles of adjuvant chemotherapy with cisplatin and doxorubicin.
  3. Standard surgery as used to treat endometrial cancer not related to the prior use of tamoxifen.
  4. Oral progesterone therapy until disease progression.
  5. Discontinuation of treatment with tamoxifen and then observation.
Explanatory Answer
Data suggest that the natural history of and prognosis for tamoxifen-associated endometrial cancers are similar to those of endometrial cancers that develop in women who have not previously received this hormonal antineoplastic agent.

Tamoxifen-associated endometrial cancer should be treated as if the cancer developed in the absence of this risk factor. Aggressive surgery, avoidance of surgery, or use of adjuvant chemotherapy to treat such patients is inappropriate.

Case 5
  • A 58- year old woman is diagnosed with advanced ovarian cancer . Because breast cancer developed before the age of 40 in two first-degree relatives (an older sister and an aunt), the woman elects to have genetic testing and is found to have a BRCAI mutation. She asks your advice about the value of a prophylactic bilateral oophorectomy for her daughter (age 38), who has also tested positive for a BRCAI mutation.
  • Which of the following statements most accurately reflects current knowledge regarding the daughter’s future risk of ovarian cancer following prophylactic bilateral oophorectomy ?
Objectives
  1. This procedure will essentially eliminate the risk of an ovarian-like cancer.
  2. This procedure has not been shown to have a substantial impact on the subsequent development of an ovarian-like cancer.
  3. Because it is not possible to remove all tissue at risk, this procedure has little role in the prevention of ovarian-like cancers in women with a genetic abnormality.
  4. The procedure is safe and effective, and there will be little negative impact resulting from estrogen deprivation in a 38 year old.
  5. There appears to be a substantial short-term decreased risk for development of an ovarian-like cancer, but long-term risk reduction remains uncertain.
Correct Answer
  1. This procedure will essentially eliminate the risk of an ovarian-like cancer.
  2. This procedure has not been shown to have a substantial impact on the subsequent development of an ovarian-like cancer.
  3. Because it is not possible to remove all tissue at risk, this procedure has little role in the prevention of ovarian-like cancers in women with a genetic abnormality.
  4. The procedure is safe and effective, and there will be little negative impact resulting from estrogen deprivation in a 38 year old.
  5. There appears to be a substantial short-term decreased risk for development of an ovarian-like cancer, but long-term risk reduction remains uncertain.
Explanatory Answer
Bilateral prophylactic oophorectomy will substantially decrease the risk of ovarian cancer for women with a BRCAI genetic abnormality.

Follow-up of these patient populations remains relatively short (less than 10 years ). Therefore, the long-term protective effect (more than 15 to 20 years) of this surgery, specifically the subsequent risk of primary peritoneal caner, remains undefined.

Impact of estrogen deprivation, which can cause menopausal symptoms and bone loss, when contemplating having prophylactic oophorectomy.

Case 6
  • A 49 year old woman is seen be her family physician because of lower abdominal discomfort of three months duration. Physical examination and computerized tomography (CT) of the abdomen and pelvis demonstrate a large (eight centimeters by 12 centimeters) pelvic mass. The lymph nodes are not enlarged, and there is no evidence of ascites. The CA-125 antigen level is 47 U/mL. During exploratory laparotomy, a stage 1 granulosa cell tumor is found and is completely resected.
  • Which of the following is the most appropriate next step in the treatment of this patient ?
Objectives
  1. Observation until relapse.
  2. Six cycles of carboplatin plus paclitaxel.
  3. Four cycles or cisplatin plus etoposide.
  4. Radiation therapy to the whole abdominal cavity.
  5. CT of the abdomen and pelvis every six months for three to four years.
Correct Answer
  1. Observation until relapse.
  2. Six cycles of carboplatin plus paclitaxel.
  3. Four cycles or cisplatin plus etoposide
  4. Radiation therapy to the whole abdominal cavity.
  5. CT of the abdomen and pelvis every six months for three to four years.
Explanatory Answer
The risk of recurrence in this setting is relatively low and there is no evidence that adjuvant chemotherapy or radiation to the whole abdominal cavity will prolong survival.

If abdominal symptoms develop, CT scan is an appropriate diagnostic test.

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